Caesarean section is one of the global leading surgical procedures performed in obstetrics and

gynecology practice . Surgeons have traditionally practised hair removal in cesarean delivery as part of
preoperative preparation of the operative field and this practice still enjoys wide application 1.
Infections that occur in the wound created by an invasive surgical procedures as in cesarean sections are
generally referred to as surgical site infections (SSIs) and following CS, women are up to 20-times more
likely to develop SSIs compared to those who deliver vaginally2. The severity of surgically site infection
in cesarean section ranges from superficial incisional skin infection(superficial; involving the skin and
subcutaneous tissues) through deep incisional(involving the deeper soft tissues of incision; muscle and
fascia) to organ space infections(involving any part of the anatomy other than the incised body layers
above; that is, skin, subcutaneous, fascia and muscle)3.
Although the risk of developing SSI from cesarean section has significantly decreased in the last three
decades mainly owing to improvements in hygiene conditions, antibiotic prophylaxis, sterile procedures,
and other practices, the occurrence of SSI in cesarean section is expected to increase given the
1
A comparison of postoperative wound infection rates after preoperative
hair removal with razors versus clippers in a sub-urban setting
Bamidele I. Omolabake, Ken N. Ozoilo

Karegoudar JS, Prabhakar PJ, Vijayanath V, Anitha MR, Surpur RR, Patil VM. Shaving versus
depilation cream for pre-operative skin preparation.
Indian J Surg. 2012;74(4):294-7.

Waddington C. Changing behaviour: evidence based

practice supporting hair removal with clippers. ORL
Head Neck Nurs. 2008;26(4):8-12.

Lefebvre A, Saliou P, Lucet JC, Mimoz O, KeitaPerse O, Grandbastien B, et al. Preoperative hair
removal and surgical site infections: network metaanalysis of randomized controlled trials. J Hosp
Infect. 2015;91(2):100-8.

Buteera AM. Prevention of perioperative wound

infections. East Cent Afr J Surg. 2008;13(2):3-7.

2
van Dillen J, Zwart J, Schutte J, van Roosmalen J (2010) Maternal sepsis: epidemiology,
etiology and outcome. Curr Opin Infect Dis 23: 249-254

Horan TC, Andrus M, Dudeck MA (2008) CDC/NHSN surveillance definition of

health care-associated infection and criteria for specific types of infections in the acute
care setting. Am J Infect Control 36: 309-332

Post-caesarean section surgical site infections: A retrospective

audit and case note review at an Ethiopian referral hospital
Rose AF, Fekad B, Moore JN and Graham WJ.
Academic Foundation Doctor, NHS Greater Glasgow and Clyde, UK
Consultant Obstetrician and Gynaecologist, Felege Hiwot Referral Hospital, Ethiopia
Consultant Anaesthetist, Aberdeen Royal Infirmary, UK
Obstetric Epidemiology, London School of Hygiene and Tropical Medicine, UK

3
A comparison of postoperative wound infection rates after preoperative
hair removal with razors versus clippers in a sub-urban setting
Bamidele I. Omolabake, Ken N. Ozoilo
continuous rise in the incidence of cesarean deliveries4. Infection of the surgical site following caesarean
delivery increases the length of hospital stay, readmission rate, maternal morbidity, mortality and
financial burdens for individuals and communities. While preoperative hair removal is mainly done to
reduce postoperative wound infections in cesarean sections, several authors have identified the method
and timing of hair removal as important contributors to surgical wound infections 5. The methods used in
hair removal include shaving with razor blades, hair-clipping with clippers and the use of depilatory
creams. The present consensus appears to favour the use of clippers and depilatory creams over razors
for hair removal6. However, pre-operative razor shaving is still commonly used in surgical practice in
developing countries including Nigeria7. This may be because razor shaving is cheap, convenient, widely
available, and easily accessible. Also, the process is fast, does not require training and is applicable in
ubiquitous settings. In contrast, clippers are expensive, not as readily available
and require some training for its effective use8.

4
Postcesarean wound infection: prevalence, impact, prevention, and management challenges
Sivan Zuarez-easton1 Noah Zafran1,2 Gali Garmi1,2 Raed Salim1,2
1
Department of Obstetrics and
Gynecology, emek Medical Center,
Afula, 2Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa,

5
Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection.
Cochrane Database Syst Rev. 2006;(3):1-28.

Abdullah EM, Samnani S, Salahuddin S. Timings of pre-operative hair removal using surgical clipper
and it’s impact on wound infection. Pak J Surg. 2014;30(3):227-30.

Kattipattanapong W, Isaradisaikul S, Hanprasertpong C. Surgical site infections in ear

surgery: hair removal effect; a preliminary, randomized trial study. Otolaryngol Head Neck
Surg. 2013;148(3):469-74.

Kjonniksen I, Anderson BM, Sondenaa VG, Segadal L. Preoperative hair removal- a systematic
review. AORN J. 2002;75(5):928-38.

6
Millard M, Hedden JJ. Hair removal methods. Manag Infect Control. 2008;2:84-97.

Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection. Cochrane
Database Syst Rev. 2006;(3):1-28.

Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane
Database Syst Rev. 2011;(11):1-49.

7
Lefebvre A, Saliou P, Lucet JC, Mimoz O, KeitaPerse O, Grandbastien B, et al. Preoperative hair
removal and surgical site infections: network metaanalysis of randomized controlled trials. J Hosp
Infect. 2015;91(2):100-8

8
Adisa AO, Lawal OO, Adejuyigbe O. Evaluation of two methods of preoperative hair removal and their
relationship to postoperative wound infection. J Infect Dev Ctries. 2011;5(10):717-22.
The relevance of the practice of hair removal in elective cesarean delivery can be attributed to its
benefits which include:
1.Facilitation of surgery: Hair in the operative field may interfere with exposure and creation of incision,
with hair dropping into the incised wound during cesarean section. Suturing during closure of the skin
incision may be interfered with by the presence of hair9.
2. Facilitation of adhesive draping and dressings10: Hair at the operative field during cesarean section
may stick to adhesives drapes and dressing, making the application of these less precise and more time -
consuming.
3. Reduction of surgical site infections (SSI): Hair removal is believed to reduce wound infections 11. The
explanation for this is that hair is not sterile and may be a source of bacteria with potential to
contaminate the surgical incision during cesarean section and result in wound infection 12. So, removing
the hairs before making the skin incision will exclude a potential source of contamination. There are
studies supporting the role of preoperative shaving in reduction of SSI in elective CS. Mukesh 13 and
colleagues for instance, reported an SSI rate of 6.45% using clippers, 0% using depilatory creams and
8% with no hair removal. Other authors have found no impact between hair removal and no hair
removal14. Yet, others have found an increased infection rate when hair is removed preoperatively,
particularly with the use of razors15.

9
A COMPARISON OF POSTOPERATIVE WOUND INFECTION RATES AFTER PREOPERATIVE HAIR REMOVAL WITH
RAZORS VERSUS CLIPPERS IN JOS UNIVERSITY TEACHING HOSPITAL
DR. OMOLABAKE ISRAEL BAMIDELE (MBBS, BENIN)
10
Broekman M, van Beijnum J, Peul WC, et al. Neurosurgery and shaving: What’s the evidence? A review. J
Neurosurg. 2011;115(4):670–8. Bansal M, Sethi GS.

Comparative study of shaving and depilatory cream for hair removal in inguinal hernia surgical site preparation.
Indian J ApplRes. 2016;205(2):205–7.

Sebastian S. Does preoperative scalp shaving result in fewer postoperative wound infections when
compared with no scalp shaving? A systematic review. J Neurosci Nurs. 2012;44(3):149–56.

11
Jose B, Dignon A. Is there a relationship between preoperative shaving (hair removal) and surgical site
infection? J Perioper Pr. 2013;23(1–2):22–5.
12
de Koos PT, McComas B. Shaving versus skin depilatory cream for preoperative skin preparation. A prospective
study of wound infection rates. Am J Surg. 2003;145(3):377–8
13
Mukesh KA, Gupta V, Kant K, et al. A prospective study of evaluation of different methods of preoperative hair
removal and their relationship to postoperative wound infection. J Med Sci Clin Res. 2014;2(2):2669–75.
14
Lefebvre A, Saliou P, Lucet JC, et al. Preoperative hair removal and surgical site infections: network meta-analysis
of randomized controlled trials. J Hosp Infect. 2015;91(2):100–8.

Kattipattanapong W, Isaradisaikul S, Hanprasertpong C. Surgical site infections in ear surgery: hair removal effect; a
preliminary, randomized trial study. Otolaryngol Head Neck Surg. 2013;148(3):469–74.

Shereif WI, Hassanin AA. Impact of the time and method of preoperative hair removal on surgical site infection in
lower abdominal surgery. Med J Cairo Univ. 2009;77(3):107–13.
15
Muhammad T, Rizvi R. Cranial neurosurgery without removing scalp hairs. J Surg Pak. 2015;20(5):96–9.

Millard M, Hedden JJ. Hair removal methods. Manag Infect Control. 2008;2:84–97.

Kshirsagar AY, Patil RK, Nangare NR, et al. Role of pre-operative no hair removal on surgical site infection. JEMDS.
2013;2(19):3326–33.
4. Reduction of pain and discomfort associated with wound dressing changes: Adhesive wound
dressings are commonly used in preoperatively management of surgical wounds following an elective
cesarean section. When these are removed, adherence to hair at the site increases pain and discomfort
associated with the procedure.
5. Psychological reasons: Hair is generally perceived to be associated with a lack of cleanliness 16.

The different methods used in hair removal during elective CS which include shaving with razor blades,
hair-clipping with clippers and the use of depilatory creams have been studied by various researchers
and the present consensus favours the use of clippers and depilatory creams over razors for hair
removal . For instance, the Centre for Disease Control and Prevention, Atlanta, USA, (CDC) guidelines
recommend that if hair removal is necessary in elective CS, this should be done preferably with clippers
and immediately before surgery17. The Norwegian Centre for health and Technology Assessment
guidelines recommends the use of clippers or depilatory creams18. While the British Hospital Infection
Society Working Party guidelines recommends using depilatory creams the day before CS 19. Similarly, the
Association of Operating Room Nurses (AORN) recommends that clippers and chemical depilation are
methods of choice if hair is to be removed before elective CS. The American College of Surgeons ACS
recommends morning- of -surgery hair clipping at the surgical site if hair is to be removed before
elective CS. In Nigeria, Adisa20 found that in patients undergoing clean surgical operations , 27.9% of the
razor shaved group had trauma compared to the 3.9% depilatory cream group. They concluded that
preoperative hair removal with razor predisposes the skin to injuries which significantly influence
preoperative wound infection rates adversely. A finding, corroborated by other studies. No Nigerian
study was identified or accessed in the literature that compared clippers and razors in hair removal
during elective CS. Adisa21 suggested that the use of depilatory creams should be favoured over razor
shaving. However, the latter is still commonly used in surgical practice in developing countries including
Nigeria22. Possible reasons for this include problems associated with the use of depilatory creams.
Chemical depilation is a relatively slow process, requiring skin contact for between 5 to 20 minutes for
effective depilation. Also, there are concerns about the incidence of allergic or irritant reactions noticed
with the use of chemical depilation. This may further predispose paradoxically to wound infection 23 .
Various bodies have recommended both clippers and depilatory creams for use over razors where
preoperative shaving is necessary in cesarean section24. Despite this, consensus is still lacking between
16
Mukesh KA, Gupta V, Kant K, et al. A prospective study of evaluation of different methods of preoperative hair
removal and their relationship to postoperative wound infection. J Med Sci Clin Res. 2014;2(2):2669–
17
Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst
Rev. 2011;11:1–49.
18
Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst
Rev. 2011;11:1–49.
19
Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst
Rev. 2011;11:1–49.
20
Adisa AO. Evaluation of two methods of preoperative hair removal and their relationship to postoperative
wound infection. Faculty of surgery, National Postgraduate Medical College of Nigeria ; 2010.
21
Adisa AO. Evaluation of two methods of preoperative hair removal and their relationship to postoperative
wound infection. Faculty of surgery, National Postgraduate Medical College of Nigeria ; 2010.

22
Abdullah EM, Samnani S, Salahuddin S. Timings of pre-operative hair removal using surgical clipper and it’s
impact on wound infection. Pak J Surg. 2014;30(3):227–30
23
Karegoudar JS, Prabhakar PJ, Vijayanath V, et al. Shaving versus depilation cream for pre-operative skin
preparation. Indian J Surg. 2012;74(4):294-7.
24
Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst
Rev. 2011;11:1–49.
the choice of clipper versus depilatory cream in hair removal in terms of adequacy of hair removal, cost-
effectiveness of the process and wound outcomes (especially wound infections) resulting from such
interventions. There is no agreement regarding the optimal timing of each intervention 25.The disparities
in recommendations of several review groups concerning hair removal practices during elective
cesarean section have emphasised the need for clarification of the roles of these methods in the context
of better wound outcomes.

25
Tanner J, Norrie P, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst
Rev. 2011;11:1–49.